title: Safely and effectively reducing inpatient length of stay: a controlled study of the General Internal Medicine Care Transformation Initiative.
abstract: OBJECTIVE
  Whether improving the efficiency of hospital care will worsen post-discharge outcomes is unclear. We designed this study to evaluate the General Internal Medicine (GIM) Care Transformation Initiative implemented at one of the seven teaching hospitals in the Canadian province of Alberta.
  
  
  METHODS
  Controlled before-after study of GIM patients hospitalised at the University of Alberta Hospital (UAH, intervention site, n=1896) or the six other teaching hospitals in Alberta-three in Edmonton (intra-regional controls (IRC), n=4550) and three in Calgary (extra-regional controls (ERC), n=4095). The primary effectiveness outcome was risk-adjusted length of stay (LOS) and the primary safety outcome was 'mortality during index hospitalisation or all-cause readmission or death within 30-days of discharge'.
  
  
  RESULTS
  LOS for GIM patients decreased by 0.68 days at Alberta teaching hospitals between 2009 and 2012; GIM patients hospitalised at the UAH exhibited a further 20% relative decline in adjusted LOS (total reduction=1.43 days, 95% CI 0.94 to 1.92 days) from PRE to POST. Interrupted time series (ITS) confirmed that the 1.43 day reduction at the UAH was statistically significant (level change p=0.003), while the declines at the IRC (p=0.37) and ERC (p=0.45) were not. Our safety outcome did not change for UAH patients (18.4% PRE-intervention vs 17.8% POST-intervention, adjusted OR 1.02 (95%CI 0.80 to 1.31), p=0.42 on ITS), nor for those hospitalised at the IRC (p=0.33) or the ERC (p=0.73) sites.
  
  
  CONCLUSIONS
  The Care Transformation Initiative was associated with substantial reductions in LOS without increasing post-discharge events commonly quoted as proxies for quality.
authors.affiliation: Division of General Internal Medicine, University of Alberta, Edmonton, Alberta, Canada Patient Health Outcomes Research and Clinical Effectiveness Unit, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Finlay A
authors.initials: FA
authors.lastname: McAlister
authors.affiliation: Patient Health Outcomes Research and Clinical Effectiveness Unit, University of Alberta, Edmonton, Alberta, Canada Data Integration Measurement and Reporting, Alberta Health Services, Calgary, Alberta, Canada.
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Bakal
authors.affiliation: Division of General Internal Medicine, University of Alberta, Edmonton, Alberta, Canada Patient Health Outcomes Research and Clinical Effectiveness Unit, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Sumit R
authors.initials: SR
authors.lastname: Majumdar
authors.affiliation: Data Integration Measurement and Reporting, Alberta Health Services, Calgary, Alberta, Canada.
authors.forename: Stafford
authors.initials: S
authors.lastname: Dean
authors.affiliation: Division of General Internal Medicine, University of Alberta, Edmonton, Alberta, Canada Patient Health Outcomes Research and Clinical Effectiveness Unit, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Rajdeep S
authors.initials: RS
authors.lastname: Padwal
authors.affiliation: Division of General Internal Medicine, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Narmin
authors.initials: N
authors.lastname: Kassam
authors.affiliation: Division of General Internal Medicine, University of Calgary, Calgary, Alberta, Canada.
authors.forename: Maria
authors.initials: M
authors.lastname: Bacchus
authors.affiliation: Integrated Quality Management, Alberta Health Services, Edmonton, Canada.
authors.forename: Ann
authors.initials: A
authors.lastname: Colbourne
mesh_terms: D000368:Aged; D000416:Alberta; D065187:Controlled Before-After Studies; D017598:Efficiency, Organizational; D005260:Female; D006784:Hospitals, Teaching / Q000458:organization & administration / Q000706:statistics & numerical data; D006801:Humans; D007388:Internal Medicine / Q000458:organization & administration / Q000706:statistics & numerical data; D007902:Length of Stay / Q000706:statistics & numerical data*; D008297:Male; D009936:Organizational Innovation; D010043:Outcome and Process Assessment, Health Care; D010351:Patient Discharge / Q000706:statistics & numerical data; D061214:Patient Safety / Q000592:standards / Q000706:statistics & numerical data
keywords: Healthcare quality improvement; Hospital medicine; Implementation science